- While conflict may not typically result in immediate population-based increases in HIV (due to decreased exposure opportunities), conflict may lay the ground for transmission by increasing overall risk of HIV through such mechanisms described below, some of which are indirectly or directly related to GBV:
- Increased interaction among military and civilians;
- Increased levels of commercial or casual sex;
- Decreased availability and/or utilization of reproductive health and other health services;
- Increased levels of malnutrition;
- Decreased means to prevent HIV transmission (knowledge level and condom use are quiet low in conflict affected countries, reflecting the failure of media, education, and literacy and clinic-based education during and following conflict);
- Increased population missing following large internal or regional population movements (exchange of rural/urban populations undermines traditional norms governing sexual activity in rural areas);
- Emergence of norms of sexual predation and violence;
- Fragmentation of families and resultant vulnerable household structures (adapted from Mock et al, 2004).
HIV Vulnerability and Exposure Opportunity in Relation to Conflict Phase
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Conflict Phase |
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During Conflict |
Post-Conflict |
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Vulnerability |
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HIV Risk Determinants |
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Exposure Opportunity |
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Source: Ward, J 2008 and adapted from Mock, N.B. et al. 2004. Conflict and HIV: A Framework for risk assessment to prevent HIV in conflict-affected settings in Africa, Emerging Themes in Epidemiology, 1:6, pg. 5.
- Given that conflict and post-conflict settings can lay the ground for increased HIV vulnerability and exposure opportunity, it is important to address HIV and AIDS within response programs. A failure to do so can cause the impacts of HIV and AIDS to persist and grow beyond the conflict setting and influence the outcomes of the response as well as post-conflict recovery (IASC, 2010).
HIV Transmission in Conflict-affected Settings: Issues for Consideration
Much has been written about the increased risks for HIV transmission associated with armed conflict, particularly as a result of civilians’ exposure to sexual violence and exploitation. In 2000, the UN Secretary-General concluded, “Armed conflicts […] increasingly serve as vectors for the HIV pandemic, which follows closely on the heels of armed troops and in the corridors of conflict” (UNICEF, 2005). In an oft-quoted study of more than 1,000 genocide widows undertaken in Rwanda in 2001, 70 percent of rape survivors were found to be HIV-positive (AI, 2004). One study in eastern DRC suggested that increased infections in that region were a direct result of massive sexual violence.
Despite wide-scale violence against women and girls in many countries, limited data currently exists to show that this violence has increased prevalence of HIV infection at the population level (Speigel et al, 2007). This may be related to decreased exposure opportunity resulting at least in part from relative isolation and limited population movement (Mock et al, 2004). In the acute emergency stage of conflict mass killings, displacement and hiding may also reduce the incidence of infection through consensual exposure and reduce the social networks where individuals might otherwise be exposed to HIV (Spiegel et al, 2007).
Nevertheless, it should be noted that a high rate of transmission of HIV among survivors of sexual assault might not lead to a significant increase in overall HIV prevalence at the population level. In addition, it is important to consider the challenges of monitoring and evaluating HIV prevalence in conflict-affected settings when drawing conclusions from available data. Data collection is undermined by the absence of health clinics in which to undertake sentinel surveillance, as well as issues of insecurity, restricted access, lack of trained health personnel (Bayard, 2004).
- It is also important for VAWG actors working in humanitarian settings to understand who is accountable for addressing HIV issues: within the cluster approach, HIV is not considered an activity specific to any cluster or sub-cluster; it has instead been identified by the IASC as a cross-cutting issue that should be mainstreamed within all the clusters.
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Key Clusters Addressing GBV and HIV |
Potential Sub-clusters Addressing GBV and HIV |
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Health led by WHO |
Reproductive Health (RH) sub-cluster may be formed under the health cluster, of which addressing GBV and HIV are components. |
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Protection led by UNHCR |
GBV sub-cluster may be formed under the protection cluster, which can include activities to address linkages between GBV and HIV. |
Source: Ward, J. 2008 “Designing Programming to Address GBV and HIV in East, Central, and Southern Africa: A Framework for Action”, Draft Working Paper, UNFPA, Nairobi.
- In addition to the key actors above, other stakeholders must be enjoined to plan and implement strong HIV/GBV prevention and response activities reaching vulnerable at-risk populations. Activities should be integrated into emergency preparedness and response plans of multiple sectors including: Protection, Water and sanitation, Food security and nutrition, Shelter and site planning, Health, and Education. Experience has shown that military forces, peacekeepers and other armed groups can play a role in increased transmission of HIV. As such, when working in conflict and post conflict humanitarian settings these groups should also be integrated into HIV prevention and response activities (IASC, 2010).
- In a regional consultation held in Kenya in 2009 and facilitated by UNFPA, a basic framework was proposed for addressing GBV and HIV in humanitarian settings. The framework can serve as a supplement the IASC HIV Guidelines and the IASC GBV Guidelines. In general (and recognizing that different contexts may require different approaches), implementation of the framework might proceed according to the following phases:
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Acute Emergency: Focus on Provision of Direct Services and Basic Prevention |
Stable Phase: Add Capacity Building of Key Sectors to Monitor, Detect, and Address GBV/HIV |
Post Conflict: Add Addressing Laws and Policies to Improve Rights of Women and Girls |
Ensure codes of conduct for all humanitarian personnel |
Support programming with boys and men to promote gender equality |
Conduct mobilization of national and traditional leaders |
Source: Ward, J. 2008 “Designing Programming to Address GBV and HIV in East, Central, and Southern Africa: A Framework for Action”, Draft Working Paper, UNFPA, Nairobi.
Additional Tools
For more information about integrating VAWG and HIV services, see the HIV section in the Health Module.
See the guidelines for addressing HIV in humanitarian settings (IASC, 2010).
Addressing Violence against Women and HIV/AIDS: What Works? (WHO and UNAIDS, 2010). This report summarizes the presentations, discussions, and recommendations from a 2009 meeting of expert researchers, policy-makers, and practitioners regarding interventions and strategies to address the intersections of violence against women (VAW) and human immunodeficiency virus (HIV).
HIV/AIDS Prevention and Control: A Short course for humanitarian worker. Facilitator’s Manual (Women's Refugee Commission on behalf of the Reproductive Health Response in Conflict Consortium, 2004). This 5-day course on HIV/AIDS prevention and control aims to assist humanitarian workers to deepen their individual understanding of the complexities of HIV/AIDS and to equip participants with the knowledge and skills needed to improve HIV/AIDS programme design and implementation in their communities. Two CD-Roms accompany the facilitator’s manual, containing PowerPoint presentations, posters, handouts and additional resources for use both during the course and for supplemental research. Also included are audio interviews with a group of HIV-positive students from South Africa who share their stories, allowing course participants to personalize the HIV/AIDS issue.
Refugees and AIDS: What should the humanitarian community do? (Women's Refugee Commission, 2002). This resource was produced by the Women’s Refugee Commission to provide user-friendly guidance and mobilize humanitarian actors working in refugee settings to address HIV/AIDS. The document aims to stimulate policy makers, managers and implementers to strengthen their response to HIV/AIDS.
Gender Equality and HIV/AIDS Web Portal (UNWOMEN and UNAIDS) This online resource provides up-to-date information on the gender equality dimensions of the HIV/AIDS epidemic. The site aims to promote understanding, knowledge sharing, and action on HIV/AIDS as a gender and human rights issue.
What Works for Women and Girls: Evidence for HIV/AIDS Interventions (web portal)(PEPFAR/USAID and OSI). The purpose of What Works for Women and Girls: Evidence for HIV/AIDS Interventions is to provide the evidence necessary to inform country-level programming. What Works is a comprehensive review, spanning 2,500 articles and reports with data close to 100 countries, that has uncovered a number of interventions for which there is substantial evidence of success: from prevention, treatment, care and support to strengthening the enabling environment for policies and programming.